Sarah Wahlster

Objective: To characterize postdischarge opioid prescription patterns in the year after traumatic brain injury (TBI) hospitalization and examine whether early demographic, injury, and hospital-level factors predict long-term or high-risk opioid use. Setting: Harborview Medical Center, a high-volume Level I trauma center serving the WWAMI region (Washington, Wyoming, Alaska, Montana, Idaho). Participants: A total of 9647 adults admitted to Harborview Medical Center with a TBI diagnosis between January 1, 2012 and December 31, 2019 who survived their hospitalization. Design: Retrospective cohort study linking 3 data sources: the Harborview Trauma Registry, the University of Washington Medicine electronic health record system, and the Washington State Department of Health Prescription Drug Monitoring Program. Main Measures: Postdischarge opioid prescription fills were characterized using 4 Bree Collaborative metrics measured quarterly over 364 days after discharge: any opioid prescription, chronic opioids (≥60-day supply), chronic high-dose opioids (≥60-day supply and ≥50 mg/d morphine equivalent dose [MED]), and chronic opioids with concurrent sedatives. Demographic, injury, and inpatient opioid administration variables were examined as potential predictors. Results: Approximately 12% of participants filled an opioid prescription within 90 days of discharge. Among those who did, 26% had refills reflecting chronic use (≥60-day supply), of whom 54% continued filling prescriptions through 1 year postinjury. Neither demographic characteristics nor inpatient opioid administration variables, including average MED, maximum MED, or average MED in the final 48 hours of hospitalization, were significant predictors of postdischarge opioid use across any metric or quarter. Conclusion: Although most individuals with TBI do not fill opioid prescriptions after discharge, among those who do, 1 in 4 follow trajectories consistent with chronic use. The absence of identifiable demographic or hospital-level predictors suggests that routine electronic health record–derived variables are insufficient for risk stratification in this population and highlights the risk of relying on unvalidated demographic proxies in clinical prescribing decisions.

Concerns about reproducibility, transparency, and research waste have intensified debates about trust in medical research and health-related sciences. Although Open science initiatives aim to address these challenges, their role in undergraduate medical education remains underexplored. Undergraduate medical education typically emphasizes appraisal of published evidence but pays less attention to how research is conducted, governed, and disseminated. This article proposes an international conceptual framework that positions Open science as part of professional formation in undergraduate medical education. The framework comprises three domains: epistemic transparency, ethical responsibility, and professional identity formation. Together, they describe how learners engage with knowledge production, uncertainty, and responsibility. Rather than prescribing curricular models, the framework offers adaptable principles that can be mapped onto existing structures such as competency-based programs in diverse contexts. By framing Open science as a formative orientation rather than a technical skill set, it links medical education to professional responsibility and the public role of medicine.

Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence. By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC. Through an iterative consensus process, 3 simulation cases addressing BD/DNC confounders were developed and implemented across high-fidelity and low-fidelity settings. Neurology residents and neurocritical care fellows were recruited by email from 6 academic centers in the United States. Participants each completed one case and received debriefing. Learning objectives were assessed using a 17-item, 5-point Likert pre/postsurvey assessing confidence across 4 BD/DNC domains: “Setup and Family Counseling,” “Prerequisites,” “Neurologic Examination,” and “Apnea Test and Declaration of BD/DNC.” Composite domain medians were compared using the Wilcoxon signed-rank test, and change scores (post–pre) were compared between fidelity groups using the Mann-Whitney U test. Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: “Setup and Family Counseling,” 4 [3.5–4] to 4.5 [4–5]; “Prerequisites,” 4 [4–5] to 4.5 [4–5]; “Neurologic Examination,” 4 [4–4] to 4.5 [4–5]; and “Apnea Test and Declaration of BD/DNC,” 3 [3–4] to 5 [4–5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5. This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.

Intravenous ketamine is increasingly used for refractory and super-refractory status epilepticus (RSE/SRSE), yet its efficacy and optimal use remain uncertain. We therefore aimed to synthesize the available evidence to quantify the effectiveness of ketamine in achieving seizure cessation and to explore differences in treatment characteristics between patients who respond and those who do not. We conducted a systematic review and meta-analysis to estimate the pooled seizure cessation rate associated with intravenous ketamine. Secondary analyses compared ketamine initiation timing, dosing, and infusion duration between patients who achieved seizure cessation (responders) and those who did not (nonresponders). Fourteen studies comprising 388 adult patients (249 responders, 139 nonresponders) were included. The pooled seizure cessation rate with ketamine was 64% (95% CI 49%-76%) with moderate heterogeneity (I ² = 54.1%). Sensitivity analysis showed no single study substantially influenced results, supporting robustness. Responders received ketamine earlier (3.2 ± 2.6 days) than non-responders (4.3 ± 2.6 days), mean difference of -0.90 days (95% CI: -1.31 to -0.49; p < 0.0001). The mean maintenance dose was 2.5 ± 1.4 mg/kg/hr (responders: 2.5 ± 1.3; nonresponders: 2.6 ± 1.4), with no significant difference between groups (mean difference -0.14 mg/kg/hr; 95% CI -0.45 to 0.18; p = 0.39). Infusion duration averaged 5.0 ± 4.2 days in both groups, with no significant difference (mean difference -0.07 days; 95% CI -1.02 to 0.88; p = 0.88). Ketamine discontinuation due to adverse events was rare (0.7%, 3/55 patients). Intravenous ketamine demonstrates consistent effectiveness and safety as an adjunctive therapy in RSE/SRSE. However, the timing of initiation cannot be reliably linked to improved clinical outcomes given current methodological limitations and heterogeneity across studies. Future prospective research using standardized definitions and rigorous temporal data collection is needed to clarify whether the timing of ketamine initiation independently influences therapeutic success and to define its optimal integration within established status epilepticus (SE) treatment algorithms. The systematic review was registered (June 7, 2024) with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024549523).

Background Neuromuscular blocking agents (NMBA) have been used in mechanically ventilated patients with moderate-to-severe acute respiratory distress syndrome (ARDS), in cases of clinically significant ventilator dyssynchrony, and in patients with elevated intracranial pressure (ICP). However, practice patterns around NMBA utilization and their impact on outcomes in acute brain injury (ABI) remain insufficiently explored. Methods This study carried out a post hoc analysis of a multicenter, prospective observational study (NCT03400904) including adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required invasive mechanical ventilation (IMV) ≥ 24 h. Patients who received NMBA during their first week of ICU stay were propensity matched to those who did not. Results Propensity score matching was performed in 1482 patients; among the matched cohort (n = 258), 33.3% (n = 86) received NMBA. NMBA utilization varied from 0% to 59.3% across countries. Multivariable regressions demonstrated associations between NMBA use and utilization of intraparenchymal ICP monitoring (odds ratio, OR 2.06; 95% confidence interval, CI 1.16–3.76), extraventricular drain placement (OR 2.18; 95% CI 1.18–4.05), higher PaCO₂ values (OR 1.04; 95% CI 1.01–1.09), and moderate-to-severe ARDS (OR 2.40; 95% CI 1.16–5.05). NMBA use was associated with lower hospital mortality (OR 0.35; 95% CI 0.11–0.99) and prolonged IMV duration (OR 1.56; 95% CI 1.38–1.76), but not with reintubation rates or tracheostomy placement. Conclusions NMBA utilization varied widely, highlighting the need for more evidence to guide clinical practice. NMBA were most commonly used in patients with ICP monitoring or moderate-to-severe ARDS; associations with outcomes warrant further exploration in randomized controlled trials.